1. Experiences of a junior doctor
setting up
Mental Health Services in
Somaliland
Dr Djibril I.M Handuleh
Msc International Health graduate student,
Universitat Heidelberg, Germany

2. Background on Somaliland
Somaliland Vs Somalia
• Somaliland is a de facto
state that declared its self
independence from Somalia
in 1991.
• Though not internationally
recognized it is part of
Somalia.
• Recovering from civil war
with rebuilding efforts and
relative stability health
services are being
redeveloped including

3. Mental Health Services in
Somaliland
• Mental Health services are available in major
towns in the country. Hargeisa
Berbera
Borama

4. Other major mental health player:
Traditional Healers
• Mostly spiritual healers mixing traditional
healing practices and sometimes prescriptions
of medications
Borama, 2012

5. My experience with mental health
systems in Somaliland
• Mental Health Hospitals
• Traditional Healer centers
• Weaker government oversight
• Poor financial systems
• Work force is limited
• Some places have no access to health care
including mental health.
• Somaliland has its own mental health policy in
place.

6. Setting mental health service from
Scratch: Case study of Borama
• Growing city just close
to Djibouti and
Ethiopian border
• Population :
200,000( estimated)
• Mix of local and IDP
• No mental Health
services before 2010
Sheriff, R. S., & Whitwell, S. (2012). An
innovative approach to integrating mental
health into health systems: strengthening
activities inSomaliland.Intervention, 10(1),
59-65.

7. How the Mental Health service
was established?
• Partnership between
Amoud University and
the King’s College
London IOPPN in the
famous partnership :
The King’s THET
Somaliland
Partnership(KTSP).
• http://www.kcl.ac.uk/lsm/resear
ch/divisions/global-
health/partnerships/index.aspx

8. The basic components of mental
health service
• Phase 1 2011-13 With
UK partners
1. Set up mental health outpatient
service
2. Set up inpatient unit
3. Community based mental health
service
4. Integrated mental health into
maternal care services
5. Set up prison MH
6. Set up MH practice in Schools
7. Integrated psychiatry into
Medical education
• Phase II 2013-2018
with Swedish
Development agency
1. Strategy to integrate
mental health into
Primary health care
2. Trained Female
community workers
3. Mental health along
with maternal and child
health services

9. Mental Health service in
outpatient and inpatient care
• In 2011, outpatient
service with two main
aims
• Offer outpatient care
for patients
• Clinical attachment site
for psychiatry
particularly
undergraduate medical
and nursing student in
Borama.

10. Mental Health in Primary care
setting
• Work with primary care
doctors and
nurses/midwives
• Trained them on
identification and
referral to health
service
• Community led home
visits for patients who
could not access health
care with local women

11. Mental health in prisons
• Worked with line ministries
• Local prison authorities
• Police department
Objectives
1. Train them on common mental health disorders
2. Referral to services
3. Trained prison nurse and doctor on mental health disorder
4. Weekly observation of patients in prison
5. Workplan with judiciary system on medico-legal aspects of mental health
• Handuleh J., McIvor R. (2014) “A novel prison mental health in-reach
service in Somaliland: a model for low income countries?” International
Psychiatry, 11(3):61-64.

12. Mental health in Schools
• Trained school teachers Primary- High School
on common mental health disorders. Sample
of 100/800 teachers
• Worked with MOE on setting up the
workshops and referral for students and
teachers with mental health disorders
• Once weekly psychiatry service for them in
outpatient service
Handuleh, J., Whitwell, S., & Fekadu, D. (2013). Report: School mental
health project in Somalia. Arab Journal of Psychiatry, 24(1), 46-51.

13. Mental health, community and the
civil society
• community based discussion forums on
mental health service for Borama.
• Forum
A.Local government
B.Civil society
C.Academia
D.Youth and women clubs

14. Mental health ward
• Community and local MOH agreed to set up
mental health ward in Borama Hospital
• Partnership with KCL on training aspects
where wide range mental health professionals
teach and work with local health
professionals.
Handuleh, J. (2013). Transforming a Dumping
Site Into a Psychiatric Inpatient Unit in
Somalia. The American journal of
psychiatry, 170(11), 1248.

15. Mental Health and integration with
Primary Health care
• Female community health workers and
doctors work daily in the Borama community
and two nearly villages
• FCHW are increased from 10 to 55 people
• People from the community with their
community leaders.
• Community cover the costs of the medications
and the Swedish partners already preparing
them to take over.

16. 2013- Perfect storm comes in
mental health into primary health care
• A senior Somali born Swedish
psychiatrist and SIDA
• Training of Female community health
workers
• Work in 4 primary care centers
• First integration of mental health into
primary health care
• Nov 2013, Somalia puts mental
health into its national health
services package at primary care.
• Somaliland is working on MH Plan
Handuleh, J. I., Gurgurte, A. M., Elmi, A.,
Aye, I. M., Abubakr, F., Kayd, M.
A., ... & Abdi, Y. A. (2014). Mental
health services provision in
Somaliland. The Lancet
Psychiatry, 1(2), 106-108.
2012 talk Topic: can we follow
WHO PHC integration approach?

17. Community ownership and
leadership
• Community had teams to suggest the
structure of health services, patient groups
and advocacy, Somali diaspora community
and the general public.
• Mental health owned by the society and
integrated actively into health services.
Handuleh, J. (2012). Experiences of a junior
doctor establishing mental health services in
Somaliland. Intervention, 10(3), 274-278.

18. Clinical notes from the field
• Cultural
• Local
• Migration and mental health
• Conflict and mental health

19. Local interpretations of mental
health
• Ghosts
• Possessions
• Witch craft
• Jinn
• Mental Health does not exist
• It is not for me
• Religion is protective

20. Local aspects of mental health
• Every community has its own culture, norm,
traditions
• Somali society is conservative and families are
nuclear.
• Mental Health is new to the society including
the diaspora community. There is growing
community in Germany often not reported.
• Autism among Somalis in many English
speaking western countries particularly USA.

21. Clinical examples
• Somatisation disorder
• Epilepsy is usually regarded as psychotic
• Mental Health in obstetrics
• Mental Health and its religious context
• Mental health and human rights aspects like
prisons, internally displaced and refugees in
the Somali context.

22. ANY QUESTIONS
Thank you